Course Code: REL-PAC-0-ORR
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2025
Learning Objectives:
Implement skills for good observation - what to watch for and how to observe.
Report your observations effectively using sound communication techniques.
Record your tasks and observations according to best practices.
Describe common types of documentation used for reporting your observations
Identify situations that caregivers have a legal obligation to report
Outline:
I.Observation, Reporting and Recording
II.Course Description
III.Course Objectives
IV.Checkpoints
V.Glossary
VI.The Care Team
VII.Important information
Obtaining Baseline information
Examples of baseline information
VIII.Communication
Communication skills
Making Observations and using the information
IX.Client Care Process
Reporting your Observations
Give Clear Descriptions
Use Plain Language
Be Descriptive
X.Directing Your information
When to Report
XI.Using Sbar to communicate
XII.Case Study: Beth
XIII.Checkpoint 2
XIV.Watching for signs and symptoms
Observing changes in senses
Levels of consciousness
Pain
Mood and Behavioral changes
Sudden Loss of Hearing
Fever and chills
Vital Signs
Heart and Lungs
Chest Pain
Changes in breathing
Cough
XV.Assessing Intake and Elimination
Excessive thirst
Changes in Appetite
Nausea and/or Vomiting
Dehydration signs
Changes in urine characteristics
Bowl changes
XVI.Assessing Skin, Extremities, functional ability
Changes in skin color
New wounds or drainage
Edema
Changes in functional ability
XVII.Checkpoint 3
XVIII.Use specifics
XIX.Recheck
XX.SBAR
XXI.Objective information
XXII.Documentation
Care Plans
Nursing Notes
Log Books
Electronic Medical Record
XXIII.Documentation Do's and Don'ts
Abbreviations
Meanings of Abbreviations
Meanings of Abbreviations
XXIV.Reporting Abuse and Neglect
Anonymous Reporting
XXV.Checkpoint 4
XXVI.Observations are Important
Communication
When to use SBAR
Baseline information
XXVII.Conclusion
XXVIII.End of lesson
Instructor: Laura L. Morgan, MSN, RN, NEA-BC
Laura L. Morgan, MSN, RN, CCRP, NEA-BC, currently serves as the Clinical Education Specialist at Lincoln County Medical Center in Ruidoso, New Mexico. She plans, develops, implements, and evaluates educational programs for clinicians, using the most current research and clinical data, while fostering the implementation of evidence-based practice. Ms Morgan is an endorsed member of the Society of Clinical Research Associates, member of Sigma Theta Tau international honors Society of nursing, an instructor for Basic Life Support, Advance Cardiovascular Life support and a Board Certified Nurse Executive-Advanced from the American Nurses Credentialing Center.
Target Audience:
The target audience for this course is: Direct Care Staff.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.